Assessment Nursing Diagnosis Inference Goal Intervention Rationale Evaluation Subjective: Longterm: Independent
Assessment Nursing Diagnosis Inference Goal Intervention Rationale Evaluation Subjective: Longterm: Independent
Assessment Nursing Diagnosis Inference Goal Intervention Rationale Evaluation Subjective: Longterm: Independent
Diagnosis
SUBJECTIVE: disruption of skin, LONGTERM: INDEPENDENT:
“ kumikirot ang tahi ko lalo Acute pain tissue and muscle After 3 days of nursing Monitor vital To have baseline After 3 days of nursing
na kapag gumagalaw” as related to integrity intervention the client signs data and to intervention the client
verbalized by the client disruption of will report absence of monitor progress reported absence of
skin, tissue pain as manifested by: of treatment pain as manifested by:
OBJECTIVE: and muscle damage nerve
integrity ending promote perineal Reduce
Pain scale of 6/10 secondary to pain scale of exercise (kegel’s discomfort and pain scale of
episiorraphy 0/10 after 2 exercise)and improve 0/10 after 2
Facial grimace localized pain days comfortable circulation in the days
noted when stimuli sitting position perineum area
changing position no facial no facial
grimace when instruct patient Relax skeletal grimace when
Slow movements converted to moving after 2 to do deep muscle thus moving after 2
noted when walking electrical signal by days breathing reducing tension days
nociceptor exercise
Seeking out her her can move moved freely
husband when freely without schedule Prevent fatigue without
going to the travel to brain assistance after adequate rest and conserve assistance after
restroom 3 days periods energy 3 days
DEPENDENT:
To relieve mild
Administer and moderate
Mefenamic Acid pain
(Ponstan SF)
500mg/cap TID
PO
REFERENCE: REFERENCE:
Kozier & Erb’s Maternal and Child
Fundamentals of Health Nursing Vol.1 6th
Nursing 8th edition edition Page 430
Page 1193